PAS Annual Meeting 2013

WASHINGTON – The new Diagnostic and Statistical Manual of Mental Disorders criteria for autism spectrum disorder might significantly affect the diagnosis of ASD in very young children, a retrospective analysis has shown.

Only 35% of a sample of children diagnosed with ASD before age 3 based on DSM-IV criteria retained the diagnosis when DSM-5 criteria were applied.

"The strict nature of the criteria in a population whose symptomatology may be emerging is at odds with an early diagnosis model," said Dr. Lisa H. Shulman, director of the Rehabilitation, Evaluation and Learning for Autistic Infants and Toddlers program at the Albert Einstein College of Medicine, New York.

"Clearly, prospective studies on the impact of DSM-5 on early diagnosis are needed," she said at the annual meeting of the Pediatric Academic Societies (PAS).

Studies of the impact of the new criteria on diagnosis of ASD have focused on school-age children. Dr. Shulman and her coinvestigators looked at younger children, examining all the children who had been diagnosed with ASD by 3 years of age based on a multidisciplinary evaluation at their center during 2003-2010. Diagnoses were based on DSM-IV criteria. Childhood Autism Rating Scale (CARS) scores also were examined, however, and cognitive testing was completed in some of the children.

To determine how many of the children would retain the diagnosis using DSM-5 criteria, an algorithm was used to map data from the DSM-IV and the CARS scores onto the DSM-5 criteria. Of 237 children who had been diagnosed with ASD by age 3 at the inner-city early intervention program, only 84 children (35%) met the criteria for ASD using the DSM-5 criteria.

The children whose diagnosis was retained using DSM-5 criteria were significantly more likely to have had higher CARS scores (38.3 vs. 33.5), which are indicative of more severe social impairment. They also had a trend toward lower cognition, with 34% of those with an IQ of less than 70 diagnosed under DSM-5 criteria, compared with 12% with IQ greater than 70, Dr. Shulman reported.

The potential of the DSM-5 criteria to diagnose the more impaired children preferentially might present an obstacle to diagnosis for the children most likely to benefit from early intervention – those with the mildest symptomatology, she said.

To be classified as having ASD using the DSM-5 criteria, a child has to meet each of three categories of social-communication criteria: deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors used for social interaction; and deficits in developing and maintaining relationships and adjusting behavior to social contexts appropriate to developmental level.

In addition, a child also must have at least two out of four types of restrictive/repetitive patterns of behavior, interests, or activities: stereotyped or repetitive speech, motor movements, or use of objects; excessive adherence to routines or ritualized patterns of verbal or nonverbal behavior; highly restricted fixated interests that are abnormal in intensity or focus; and hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

The group of social-communication criteria least commonly met by the children in the study was "deficits in developing relationships." The specific criteria included in this group – difficulty sharing imaginative play, difficulty in making friends, and absence of interest in people – are especially challenging to apply to and evaluate in young children, said Dr. Shulman, associate professor of pediatrics at Albert Einstein.

Only 61% of the children met at least one of the criteria in this category. "For very young children, where we’re not in the situation to have information or parental concerns regarding making friends, we’re left with ‘absence of interest in people’ – a pretty extreme criteria," she said.

Three of the four "restrictive/repetitive" interests were reported in less than half of the children. While repetitive use of objects or motor movements was present in 89%, excessive adherence to routines was reported in 28%, restricted interests in 41%, and hyper-hypo sensitivity in 25%.

The low rate of hyper-hypo sensitivity was "interesting," Dr. Shulman noted, as inclusion of these sensitivities is new to the manual and "thought to be a nod to young children, who often have more of these symptoms." Consideration of CARS scores in the analysis provided some degree of a measure for these sensitivities, she noted.

The DSM-IV described five different disorders under the general category of "pervasive developmental disorders," for which diagnoses could be made based on 12 criteria; this allowed for any of 2,688 combinations of criteria to arrive at a diagnosis. Under the new version, which describes 1 disorder based on 5 out of 7 criteria being met, "only 12 combinations of criteria can arrive at a diagnosis," Dr. Shulman noted.

The children in the analysis had a mean age of 26.7 months and were 76% male, 19% white, 43% Hispanic, and 25% black.

"From our experience in New York City, a diagnosis made early is largely a valid one," Dr. Shulman said. "The kids who do best [with intervention] have the milder social impairment and the higher cognitive functioning."

Thus far, New York has had a "very generous" approach to intervention for ASD, with early intervention programs making their own diagnoses. "I’m more concerned about places that require [an outside] diagnosis in order to get ASD-specific services in early intervention programs," she noted.

The fifth edition of psychiatry’s diagnostic guide was officially released in May at the American Psychiatric Association’s annual meeting, shortly after Dr. Shulman presented the findings at the PAS meeting. The update is the first in nearly 20 years.

Dr. Shulman reported that she and her coinvestigators have no relevant disclosures.

WASHINGTON – The new Diagnostic and Statistical Manual of Mental Disorders criteria for autism spectrum disorder might significantly affect the diagnosis of ASD in very young children, a retrospective analysis has shown.

Only 35% of a sample of children diagnosed with ASD before age 3 based on DSM-IV criteria retained the diagnosis when DSM-5 criteria were applied.

"The strict nature of the criteria in a population whose symptomatology may be emerging is at odds with an early diagnosis model," said Dr. Lisa H. Shulman, director of the Rehabilitation, Evaluation and Learning for Autistic Infants and Toddlers program at the Albert Einstein College of Medicine, New York.

"Clearly, prospective studies on the impact of DSM-5 on early diagnosis are needed," she said at the annual meeting of the Pediatric Academic Societies (PAS).

Studies of the impact of the new criteria on diagnosis of ASD have focused on school-age children. Dr. Shulman and her coinvestigators looked at younger children, examining all the children who had been diagnosed with ASD by 3 years of age based on a multidisciplinary evaluation at their center during 2003-2010. Diagnoses were based on DSM-IV criteria. Childhood Autism Rating Scale (CARS) scores also were examined, however, and cognitive testing was completed in some of the children.

To determine how many of the children would retain the diagnosis using DSM-5 criteria, an algorithm was used to map data from the DSM-IV and the CARS scores onto the DSM-5 criteria. Of 237 children who had been diagnosed with ASD by age 3 at the inner-city early intervention program, only 84 children (35%) met the criteria for ASD using the DSM-5 criteria.

The children whose diagnosis was retained using DSM-5 criteria were significantly more likely to have had higher CARS scores (38.3 vs. 33.5), which are indicative of more severe social impairment. They also had a trend toward lower cognition, with 34% of those with an IQ of less than 70 diagnosed under DSM-5 criteria, compared with 12% with IQ greater than 70, Dr. Shulman reported.

The potential of the DSM-5 criteria to diagnose the more impaired children preferentially might present an obstacle to diagnosis for the children most likely to benefit from early intervention – those with the mildest symptomatology, she said.

To be classified as having ASD using the DSM-5 criteria, a child has to meet each of three categories of social-communication criteria: deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors used for social interaction; and deficits in developing and maintaining relationships and adjusting behavior to social contexts appropriate to developmental level.

In addition, a child also must have at least two out of four types of restrictive/repetitive patterns of behavior, interests, or activities: stereotyped or repetitive speech, motor movements, or use of objects; excessive adherence to routines or ritualized patterns of verbal or nonverbal behavior; highly restricted fixated interests that are abnormal in intensity or focus; and hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

The group of social-communication criteria least commonly met by the children in the study was "deficits in developing relationships." The specific criteria included in this group – difficulty sharing imaginative play, difficulty in making friends, and absence of interest in people – are especially challenging to apply to and evaluate in young children, said Dr. Shulman, associate professor of pediatrics at Albert Einstein.

Only 61% of the children met at least one of the criteria in this category. "For very young children, where we’re not in the situation to have information or parental concerns regarding making friends, we’re left with ‘absence of interest in people’ – a pretty extreme criteria," she said.

Three of the four "restrictive/repetitive" interests were reported in less than half of the children. While repetitive use of objects or motor movements was present in 89%, excessive adherence to routines was reported in 28%, restricted interests in 41%, and hyper-hypo sensitivity in 25%.

The low rate of hyper-hypo sensitivity was "interesting," Dr. Shulman noted, as inclusion of these sensitivities is new to the manual and "thought to be a nod to young children, who often have more of these symptoms." Consideration of CARS scores in the analysis provided some degree of a measure for these sensitivities, she noted.

The DSM-IV described five different disorders under the general category of "pervasive developmental disorders," for which diagnoses could be made based on 12 criteria; this allowed for any of 2,688 combinations of criteria to arrive at a diagnosis. Under the new version, which describes 1 disorder based on 5 out of 7 criteria being met, "only 12 combinations of criteria can arrive at a diagnosis," Dr. Shulman noted.

The children in the analysis had a mean age of 26.7 months and were 76% male, 19% white, 43% Hispanic, and 25% black.

"From our experience in New York City, a diagnosis made early is largely a valid one," Dr. Shulman said. "The kids who do best [with intervention] have the milder social impairment and the higher cognitive functioning."

Thus far, New York has had a "very generous" approach to intervention for ASD, with early intervention programs making their own diagnoses. "I’m more concerned about places that require [an outside] diagnosis in order to get ASD-specific services in early intervention programs," she noted.

The fifth edition of psychiatry’s diagnostic guide was officially released in May at the American Psychiatric Association’s annual meeting, shortly after Dr. Shulman presented the findings at the PAS meeting. The update is the first in nearly 20 years.

Dr. Shulman reported that she and her coinvestigators have no relevant disclosures.

WASHINGTON – The new Diagnostic and Statistical Manual of Mental Disorders criteria for autism spectrum disorder might significantly affect the diagnosis of ASD in very young children, a retrospective analysis has shown.

Only 35% of a sample of children diagnosed with ASD before age 3 based on DSM-IV criteria retained the diagnosis when DSM-5 criteria were applied.

"The strict nature of the criteria in a population whose symptomatology may be emerging is at odds with an early diagnosis model," said Dr. Lisa H. Shulman, director of the Rehabilitation, Evaluation and Learning for Autistic Infants and Toddlers program at the Albert Einstein College of Medicine, New York.

"Clearly, prospective studies on the impact of DSM-5 on early diagnosis are needed," she said at the annual meeting of the Pediatric Academic Societies (PAS).

Studies of the impact of the new criteria on diagnosis of ASD have focused on school-age children. Dr. Shulman and her coinvestigators looked at younger children, examining all the children who had been diagnosed with ASD by 3 years of age based on a multidisciplinary evaluation at their center during 2003-2010. Diagnoses were based on DSM-IV criteria. Childhood Autism Rating Scale (CARS) scores also were examined, however, and cognitive testing was completed in some of the children.

To determine how many of the children would retain the diagnosis using DSM-5 criteria, an algorithm was used to map data from the DSM-IV and the CARS scores onto the DSM-5 criteria. Of 237 children who had been diagnosed with ASD by age 3 at the inner-city early intervention program, only 84 children (35%) met the criteria for ASD using the DSM-5 criteria.

The children whose diagnosis was retained using DSM-5 criteria were significantly more likely to have had higher CARS scores (38.3 vs. 33.5), which are indicative of more severe social impairment. They also had a trend toward lower cognition, with 34% of those with an IQ of less than 70 diagnosed under DSM-5 criteria, compared with 12% with IQ greater than 70, Dr. Shulman reported.

The potential of the DSM-5 criteria to diagnose the more impaired children preferentially might present an obstacle to diagnosis for the children most likely to benefit from early intervention – those with the mildest symptomatology, she said.

To be classified as having ASD using the DSM-5 criteria, a child has to meet each of three categories of social-communication criteria: deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors used for social interaction; and deficits in developing and maintaining relationships and adjusting behavior to social contexts appropriate to developmental level.

In addition, a child also must have at least two out of four types of restrictive/repetitive patterns of behavior, interests, or activities: stereotyped or repetitive speech, motor movements, or use of objects; excessive adherence to routines or ritualized patterns of verbal or nonverbal behavior; highly restricted fixated interests that are abnormal in intensity or focus; and hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment.

The group of social-communication criteria least commonly met by the children in the study was "deficits in developing relationships." The specific criteria included in this group – difficulty sharing imaginative play, difficulty in making friends, and absence of interest in people – are especially challenging to apply to and evaluate in young children, said Dr. Shulman, associate professor of pediatrics at Albert Einstein.

Only 61% of the children met at least one of the criteria in this category. "For very young children, where we’re not in the situation to have information or parental concerns regarding making friends, we’re left with ‘absence of interest in people’ – a pretty extreme criteria," she said.

Three of the four "restrictive/repetitive" interests were reported in less than half of the children. While repetitive use of objects or motor movements was present in 89%, excessive adherence to routines was reported in 28%, restricted interests in 41%, and hyper-hypo sensitivity in 25%.

The low rate of hyper-hypo sensitivity was "interesting," Dr. Shulman noted, as inclusion of these sensitivities is new to the manual and "thought to be a nod to young children, who often have more of these symptoms." Consideration of CARS scores in the analysis provided some degree of a measure for these sensitivities, she noted.

The DSM-IV described five different disorders under the general category of "pervasive developmental disorders," for which diagnoses could be made based on 12 criteria; this allowed for any of 2,688 combinations of criteria to arrive at a diagnosis. Under the new version, which describes 1 disorder based on 5 out of 7 criteria being met, "only 12 combinations of criteria can arrive at a diagnosis," Dr. Shulman noted.

The children in the analysis had a mean age of 26.7 months and were 76% male, 19% white, 43% Hispanic, and 25% black.

"From our experience in New York City, a diagnosis made early is largely a valid one," Dr. Shulman said. "The kids who do best [with intervention] have the milder social impairment and the higher cognitive functioning."

Thus far, New York has had a "very generous" approach to intervention for ASD, with early intervention programs making their own diagnoses. "I’m more concerned about places that require [an outside] diagnosis in order to get ASD-specific services in early intervention programs," she noted.

The fifth edition of psychiatry’s diagnostic guide was officially released in May at the American Psychiatric Association’s annual meeting, shortly after Dr. Shulman presented the findings at the PAS meeting. The update is the first in nearly 20 years.

Dr. Shulman reported that she and her coinvestigators have no relevant disclosures.

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – New Zealand mothers who attended childbirth classes during pregnancy were 58% less likely to delay their infants’ first-year immunizations than were those who didn’t take the classes, Dr. Cameron Grant said at the annual meeting of the Pediatric Academic Societies.

The findings of his large prospective cohort study show that early engagement with a maternity clinician is important not only for mothers’ health, but for babies’ as well, said Dr. Grant of the University of Auckland (New Zealand).

The data were drawn from "Growing Up in New Zealand," a large, ongoing study of children’s health from birth to age 21 years; Dr. Grant is also the associate director of this project.

The birth cohort is culturally, racially, and economically diverse, and includes about one-third of the New Zealand births that occurred from April 2009 to March 2010. Mothers were contacted during their pregnancy and had face-to-face interviews when the infant was 6 weeks and 9 months old. There were also phone interviews at 16, 24, and 31 months. Four-year interviews started this year.

The immunization study included 6,822 mothers and their 6,846 children. It examined the links between infant immunization and the maternity care provided in the country. Typically, women attend childbirth preparation classes and their prenatal care is provided by a maternity clinician, usually a midwife. After birth, a community nurse provides well-child visits, but the mother and child return to their family doctor for immunizations. The New Zealand infant immunization series consists of the DTaP, hepatitis B/Hib, and conjugate pneumococcal vaccine, which are given at 6 weeks, 3 months, and 5 months. Delayed immunization was considered as not getting the 6-week immunizations by 8 weeks, or not getting the 3- or 5-month immunizations within 30 days of the due dates.

Mothers in the study are a diverse group, with 52% being white, 16% Maori, 14% Pacific Islanders, 14% Asian, and 4% other. Nearly a third was in the country’s lowest socioeconomic group. The pregnancy was the first for 42%.

Immunizations were delayed for 1,353 (20%) of the infants. Immunizations were on time for 88% of the women who attended childbirth classes, compared with 74% of those who did not, translating to a 62% risk reduction (odds ratio, 0.38).

A univariate analysis found several other significant predictors. Having a midwife significantly reduced the risk of delayed immunizations (OR, 0.43), as did going to any of the three infant well child visits (OR, 0.45).

However, after researchers adjusted for maternal ethnicity, age, and household income, only class attendance and well-child visits with a physician remained significantly associated with immunizations. Those who went to the class were 58% less likely to delay immunizations than were those who didn’t go to the class (OR, 0.42), and 24% less likely to delay than were those who had not gone to the class, but said they intended to (OR, 0.76). Women who visited their doctor for all three well-child visits were 55% less likely to delay immunizations (OR, 0.45).

During the discussion, Dr. Simon Hambidge, a professor at the Colorado School of Public Health, Denver, asked if the association could be a proxy for overall engagement with the health care system or an indicator of some more fundamental force influencing the decision to vaccinate.

"I really do think the health care system has a big role on whether immunization occurs or not," Dr. Grant said. "Moms from the poorest households had the highest intention to immunize their children, but the lowest actual immunization timeliness. I think that points to a number of barriers in health care that we should work hard to overcome, rather than just telling women it’s all up to them to get themselves organized and make sure it happens. We just have to make this more available."

The study is sponsored by a number of New Zealand and Pacific Island government agencies. Dr. Grant had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

msullivan@frontlinemedcom.com

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

msullivan@frontlinemedcom.com

WASHINGTON – Children with hypertension performed worse on tests of attention, and verbal and visual recall, according to some early findings of an ongoing study.

A low socioeconomic status seemed to amplify those problems, putting some children at an even higher risk, Dr. Marc Lande said at the annual meeting of the Pediatric Academic Societies.

"These baseline data don’t tell us why these differences occur," he said in an interview. "It is possible that the hypertension itself is causing a problem since we know that the brain is a target organ of hypertension. However, it is also possible that children with cognitive problems are more prone to develop hypertension."

He and his colleagues shared some baseline data from their prospective, multicenter study of neurocognition in children with primary hypertension. The study will eventually enroll 75 children with newly diagnosed primary hypertension and 75 matched normotensive controls. At baseline, both groups will have the same neurocognitive tests. During the following year, the hypertensive children will be treated with lifestyle management and angiotensin-converting enzyme inhibitors, if needed. After a year, all of the children will repeat the same neurocognitive tests.

So far, the cohort includes 37 children with hypertension and 24 controls. Their mean age is 15 years; about half of each group has mothers with less than a high school education – a measure used to indicate lower socioeconomic status. Obesity is present in 70% of the hypertensive group and 58% of the normotensive group. There are no significant differences in IQ, said Dr. Lande, a pediatric nephrologist at University of Rochester (N.Y.) Medical Center.

All of the children had 24-hour ambulatory blood pressure monitoring at baseline. The mean 24-hour systolic blood pressure load was 50% in the hypertensive group and 7% in the normotensive group. The mean 24-hour diastolic load was 22% in the hypertensive group and 5% in the normotensive group – despite the fact that almost 60% of these children were obese.

Dr. Lande presented his baseline data, showing that children in the hypertensive group were already experiencing some neurocognitive differences, compared with the control group.

On the baseline neurocognitive tests, children with hypertension scored worse than the controls on the Rey Auditory Verbal Learning Test (RAVLT) and the Conners’ Continuous Performance Test II (CPT II), although scores on the Spatial Span Forward (SSF) test were not markedly different.

When the comparison was limited to those children with less-educated mothers, the CPT II and SSF performance differences were amplified. The RAVLT performance was largely unaffected.

Findings were similar on three tests of executive function - the CPT II Commissions, Digit Span Backward, and Parent BRIEF Global Executive Composite – with hypertensive children performing worse on all three. When the analysis was limited to children of lower socioeconomic status, the difference was amplified, increasing from a small to moderate or moderate to large effect size.

There were four tests of memory: the RAVLT Short and Long Delay tests, the RAVLT List A Recognition test, and the CogState Maze Long Delay Recall. Overall, children with hypertension had worse performance, with effect sizes ranging from small to large. And again, when the investigators looked only at those children with low maternal education, the effect size between the groups increased. The impact seemed strongest on the RAVLT Recognition Test, in which the effect size increased from small to large.

The baseline findings were unadjusted for any other factors that might influence cognition, Dr. Lande noted. However, they do speak to the need for physicians who treat these children to be aware of the potential for learning problems, especially among children with lower socioeconomic status.

"These results are preliminary findings, which will be further elucidated as the study enrollment goes forward," he said. "We don’t know their clinical significance yet. Until they become more clear, though, clinicians should be aware of the possibility of increased learning problems in their patients with hypertension."

Dr. Lande said he had no financial disclosures

msullivan@frontlinemedcom.com

WASHINGTON – Vaccine-resistant isolates of Bordetella pertussis have appeared in Philadelphia – the first such strains to be seen in the United States.

Of 30 samples analyzed, 18 (60%) showed a variant that conferred resistance to the current vaccine formulation, Dr. Jennifer Vodzak said at the annual meeting of the Pediatric Academic Societies. The strains had developed two different mutations, each of which deleted their expression of pertactin, an outer membrane protein that helps the bacteria adhere to respiratory epithelium. Pertactin is used as an antigen in the acellular pertussis component of the Tdap vaccine.

"It seems that, responding to vaccine pressure, B. pertussis has acquired several adaptations to halt the production of pertactin," said Dr. Vodzak, an infectious disease specialist at St. Christopher’s Hospital for Children, Philadelphia.

For the past decade, pertactin-negative strains have been reported in Japan, France, and Finland. Although the bacteria lack pertactin, French studies have shown that they are just as virulent as the nonmutated strains. The bacteria have simply found a way to cause disease without that particular protein.

Dr. Vodzak and her colleagues first reported their findings in a brief correspondence to the New England Journal Medicine in February. At that time, 11 of 12 isolates cultured from 2011 and 2012 expressed the pertactin variants. Seven expressed stop codons that truncated the protein, and four expressed insertion sequences that disrupted the pertactin coding region. The investigators also noted that these mutations appeared to be unique and not related to those seen in other countries.

Since then, the team has expanded its search, attempting to pinpoint the time these variants first appeared. To do that, they randomly selected 70 samples taken from Philadelphia patients who had culture-proven pertussis from 2007 to 2012. Most (80%) of the samples were from hospitalized patients, the majority of whom (87%) were younger than 1 year. More than half of the patients were younger than 3 months old. So far, 30 of the isolates have been molecularly examined.

After pertussis immunization became widespread in the 1940s, the disease incidence dropped dramatically in the United States. But in the mid-1990s – shortly after the acellular vaccine was introduced in 1991 – a gradual resurgence began. The incidence really picked up in the early 2000s, when annual case reports jumped into the tens of thousands. There were 18,719 cases reported in 2011; in 2012, that number more than doubled, to 41,880 – the highest since 1955.

The rise in cases was temporally related to the initiation of the acellular vaccine, which carries the pertactin antigen. The acellular vaccine also confers a limited immunogenicity. This limited protection and increased surveillance and reporting – not the acellular pertactin-containing vaccine –have caused the rise in cases, according to the Centers for Disease Control and Prevention.

"It does not appear that these strains are the reason the United States has experienced a dramatic increase in the number of reported pertussis cases recently," the agency says on its pertussis pages. "But CDC will continue to closely monitor the situation before drawing any conclusions. There is also no suggestion that these new strains are causing more severe cases of pertussis," or that the mutated strains carry any antibiotic resistance.

The appearance of pertactin-negative strains does seem to parallel the recent jump in cases, but as yet there are no hard data linking these three occurrences, Dr. Vodzak said.

Right now, she added, there’s no way to know if – or when – similar pertactin-negative strains have developed elsewhere in the United States. She and her team are encouraging public health agencies to test their stored samples so a more complete picture can be drawn.

"It will be important to consider the pathogen’s adaptations as we consider both the decreased vaccine effectiveness and vaccine development," she said. "I think the next step is to look at the clinical picture of these variants."

Dr. Vodzak said she had no relevant financial disclosures. Her coauthor, Anne Marie Queenan, Ph.D., is an employee of Janssen Research and Development.

msullivan@frontlinemedcom.com

WASHINGTON – Vaccine-resistant isolates of Bordetella pertussis have appeared in Philadelphia – the first such strains to be seen in the United States.

Of 30 samples analyzed, 18 (60%) showed a variant that conferred resistance to the current vaccine formulation, Dr. Jennifer Vodzak said at the annual meeting of the Pediatric Academic Societies. The strains had developed two different mutations, each of which deleted their expression of pertactin, an outer membrane protein that helps the bacteria adhere to respiratory epithelium. Pertactin is used as an antigen in the acellular pertussis component of the Tdap vaccine.

"It seems that, responding to vaccine pressure, B. pertussis has acquired several adaptations to halt the production of pertactin," said Dr. Vodzak, an infectious disease specialist at St. Christopher’s Hospital for Children, Philadelphia.

For the past decade, pertactin-negative strains have been reported in Japan, France, and Finland. Although the bacteria lack pertactin, French studies have shown that they are just as virulent as the nonmutated strains. The bacteria have simply found a way to cause disease without that particular protein.

Dr. Vodzak and her colleagues first reported their findings in a brief correspondence to the New England Journal Medicine in February. At that time, 11 of 12 isolates cultured from 2011 and 2012 expressed the pertactin variants. Seven expressed stop codons that truncated the protein, and four expressed insertion sequences that disrupted the pertactin coding region. The investigators also noted that these mutations appeared to be unique and not related to those seen in other countries.

Since then, the team has expanded its search, attempting to pinpoint the time these variants first appeared. To do that, they randomly selected 70 samples taken from Philadelphia patients who had culture-proven pertussis from 2007 to 2012. Most (80%) of the samples were from hospitalized patients, the majority of whom (87%) were younger than 1 year. More than half of the patients were younger than 3 months old. So far, 30 of the isolates have been molecularly examined.

After pertussis immunization became widespread in the 1940s, the disease incidence dropped dramatically in the United States. But in the mid-1990s – shortly after the acellular vaccine was introduced in 1991 – a gradual resurgence began. The incidence really picked up in the early 2000s, when annual case reports jumped into the tens of thousands. There were 18,719 cases reported in 2011; in 2012, that number more than doubled, to 41,880 – the highest since 1955.

The rise in cases was temporally related to the initiation of the acellular vaccine, which carries the pertactin antigen. The acellular vaccine also confers a limited immunogenicity. This limited protection and increased surveillance and reporting – not the acellular pertactin-containing vaccine –have caused the rise in cases, according to the Centers for Disease Control and Prevention.

"It does not appear that these strains are the reason the United States has experienced a dramatic increase in the number of reported pertussis cases recently," the agency says on its pertussis pages. "But CDC will continue to closely monitor the situation before drawing any conclusions. There is also no suggestion that these new strains are causing more severe cases of pertussis," or that the mutated strains carry any antibiotic resistance.

The appearance of pertactin-negative strains does seem to parallel the recent jump in cases, but as yet there are no hard data linking these three occurrences, Dr. Vodzak said.

Right now, she added, there’s no way to know if – or when – similar pertactin-negative strains have developed elsewhere in the United States. She and her team are encouraging public health agencies to test their stored samples so a more complete picture can be drawn.

"It will be important to consider the pathogen’s adaptations as we consider both the decreased vaccine effectiveness and vaccine development," she said. "I think the next step is to look at the clinical picture of these variants."

Dr. Vodzak said she had no relevant financial disclosures. Her coauthor, Anne Marie Queenan, Ph.D., is an employee of Janssen Research and Development.

msullivan@frontlinemedcom.com

WASHINGTON – Vaccine-resistant isolates of Bordetella pertussis have appeared in Philadelphia – the first such strains to be seen in the United States.

Of 30 samples analyzed, 18 (60%) showed a variant that conferred resistance to the current vaccine formulation, Dr. Jennifer Vodzak said at the annual meeting of the Pediatric Academic Societies. The strains had developed two different mutations, each of which deleted their expression of pertactin, an outer membrane protein that helps the bacteria adhere to respiratory epithelium. Pertactin is used as an antigen in the acellular pertussis component of the Tdap vaccine.

"It seems that, responding to vaccine pressure, B. pertussis has acquired several adaptations to halt the production of pertactin," said Dr. Vodzak, an infectious disease specialist at St. Christopher’s Hospital for Children, Philadelphia.

For the past decade, pertactin-negative strains have been reported in Japan, France, and Finland. Although the bacteria lack pertactin, French studies have shown that they are just as virulent as the nonmutated strains. The bacteria have simply found a way to cause disease without that particular protein.

Dr. Vodzak and her colleagues first reported their findings in a brief correspondence to the New England Journal Medicine in February. At that time, 11 of 12 isolates cultured from 2011 and 2012 expressed the pertactin variants. Seven expressed stop codons that truncated the protein, and four expressed insertion sequences that disrupted the pertactin coding region. The investigators also noted that these mutations appeared to be unique and not related to those seen in other countries.

Since then, the team has expanded its search, attempting to pinpoint the time these variants first appeared. To do that, they randomly selected 70 samples taken from Philadelphia patients who had culture-proven pertussis from 2007 to 2012. Most (80%) of the samples were from hospitalized patients, the majority of whom (87%) were younger than 1 year. More than half of the patients were younger than 3 months old. So far, 30 of the isolates have been molecularly examined.

After pertussis immunization became widespread in the 1940s, the disease incidence dropped dramatically in the United States. But in the mid-1990s – shortly after the acellular vaccine was introduced in 1991 – a gradual resurgence began. The incidence really picked up in the early 2000s, when annual case reports jumped into the tens of thousands. There were 18,719 cases reported in 2011; in 2012, that number more than doubled, to 41,880 – the highest since 1955.

The rise in cases was temporally related to the initiation of the acellular vaccine, which carries the pertactin antigen. The acellular vaccine also confers a limited immunogenicity. This limited protection and increased surveillance and reporting – not the acellular pertactin-containing vaccine –have caused the rise in cases, according to the Centers for Disease Control and Prevention.

"It does not appear that these strains are the reason the United States has experienced a dramatic increase in the number of reported pertussis cases recently," the agency says on its pertussis pages. "But CDC will continue to closely monitor the situation before drawing any conclusions. There is also no suggestion that these new strains are causing more severe cases of pertussis," or that the mutated strains carry any antibiotic resistance.

The appearance of pertactin-negative strains does seem to parallel the recent jump in cases, but as yet there are no hard data linking these three occurrences, Dr. Vodzak said.

Right now, she added, there’s no way to know if – or when – similar pertactin-negative strains have developed elsewhere in the United States. She and her team are encouraging public health agencies to test their stored samples so a more complete picture can be drawn.

"It will be important to consider the pathogen’s adaptations as we consider both the decreased vaccine effectiveness and vaccine development," she said. "I think the next step is to look at the clinical picture of these variants."

Dr. Vodzak said she had no relevant financial disclosures. Her coauthor, Anne Marie Queenan, Ph.D., is an employee of Janssen Research and Development.

msullivan@frontlinemedcom.com

WASHINGTON – A rapid viral testing panel decreased the odds of inappropriate antibiotic use by 67% in children hospitalized with an acute respiratory illness, allowing about 6% of the children taking them to discontinue them.

Use of such a test could be part of a facility’s overall antibiotic control program, Dr. Russell McCulloh said at the annual meeting of the Pediatric Academic Societies.

"Now we need to talk about when a test like this can be used appropriately," said Dr. McCulloh, an infectious disease specialist at Rhode Island Hospital, Providence. "There is always a strong possibility for a bacterial coinfection in these patients, and that can be very hard to determine because we don’t have a gold standard test for that. Adjunctive diagnostic testing will be necessary if you’re really going to close the loop and implement this as part of an antibiotic stewardship program."

Dr. McCulloh conducted a retrospective chart review of 1,731 children admitted to the hospital for an acute respiratory illness from 2009 to 2011. He then compared the rates of antimicrobial use in children who had the rapid viral panel (809) and those who did not (922). About half of the group (860) had received antibiotics before having the test run, while 255 had received oseltamivir.

Most of the children who had a positive viral panel were prescribed oseltamivir (87%); the drug was used in about 18% of those who had a negative test. A multivariate analysis found that a positive rapid viral panel was the single biggest predictor of getting the antiviral drug, increasing the odds by more than 27 times, Dr. McCulloh said.

Younger age also had a significant association, but the odds ratio was only 1.7. Having a significant past medical history was predictive in an unadjusted analysis, but not in the final model. Abnormal chest x-ray, intensive care unit admission, and abnormal white cell counts had no significant predictive value.

The test also influenced the use of antibiotics, Dr. McCulloh said. Antibiotics were given to 11% of children who had the viral testing, but to 100% of those who did not have it. Antibiotics were used in 51% of those with a positive test, and 67% of those with a negative test. Antibiotics also were discontinued in 6% of children who had a positive viral test.

A multivariate analysis found several factors significantly associated with antibiotic use. A significant past medical history increased the odds by 7%. Stronger predictors included a codiagnosis of acute otitis media (OR 6.0), an abnormal chest x-ray (OR 2.57), and a positive blood culture (OR 3). However, a negative viral panel was associated with a 69% decreased chance of receiving an antibiotic.

The test was a big shaper of physician behavior, Dr. McCulloh said, allowing a more judicious and targeted use of antibiotics while increasing the use of antiviral medication. "Rapid viral panel testing seems to enhance physician decision-making in these patients."

Dr. McCulloh had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – A rapid viral testing panel decreased the odds of inappropriate antibiotic use by 67% in children hospitalized with an acute respiratory illness, allowing about 6% of the children taking them to discontinue them.

Use of such a test could be part of a facility’s overall antibiotic control program, Dr. Russell McCulloh said at the annual meeting of the Pediatric Academic Societies.

"Now we need to talk about when a test like this can be used appropriately," said Dr. McCulloh, an infectious disease specialist at Rhode Island Hospital, Providence. "There is always a strong possibility for a bacterial coinfection in these patients, and that can be very hard to determine because we don’t have a gold standard test for that. Adjunctive diagnostic testing will be necessary if you’re really going to close the loop and implement this as part of an antibiotic stewardship program."

Dr. McCulloh conducted a retrospective chart review of 1,731 children admitted to the hospital for an acute respiratory illness from 2009 to 2011. He then compared the rates of antimicrobial use in children who had the rapid viral panel (809) and those who did not (922). About half of the group (860) had received antibiotics before having the test run, while 255 had received oseltamivir.

Most of the children who had a positive viral panel were prescribed oseltamivir (87%); the drug was used in about 18% of those who had a negative test. A multivariate analysis found that a positive rapid viral panel was the single biggest predictor of getting the antiviral drug, increasing the odds by more than 27 times, Dr. McCulloh said.

Younger age also had a significant association, but the odds ratio was only 1.7. Having a significant past medical history was predictive in an unadjusted analysis, but not in the final model. Abnormal chest x-ray, intensive care unit admission, and abnormal white cell counts had no significant predictive value.

The test also influenced the use of antibiotics, Dr. McCulloh said. Antibiotics were given to 11% of children who had the viral testing, but to 100% of those who did not have it. Antibiotics were used in 51% of those with a positive test, and 67% of those with a negative test. Antibiotics also were discontinued in 6% of children who had a positive viral test.

A multivariate analysis found several factors significantly associated with antibiotic use. A significant past medical history increased the odds by 7%. Stronger predictors included a codiagnosis of acute otitis media (OR 6.0), an abnormal chest x-ray (OR 2.57), and a positive blood culture (OR 3). However, a negative viral panel was associated with a 69% decreased chance of receiving an antibiotic.

The test was a big shaper of physician behavior, Dr. McCulloh said, allowing a more judicious and targeted use of antibiotics while increasing the use of antiviral medication. "Rapid viral panel testing seems to enhance physician decision-making in these patients."

Dr. McCulloh had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – A rapid viral testing panel decreased the odds of inappropriate antibiotic use by 67% in children hospitalized with an acute respiratory illness, allowing about 6% of the children taking them to discontinue them.

Use of such a test could be part of a facility’s overall antibiotic control program, Dr. Russell McCulloh said at the annual meeting of the Pediatric Academic Societies.

"Now we need to talk about when a test like this can be used appropriately," said Dr. McCulloh, an infectious disease specialist at Rhode Island Hospital, Providence. "There is always a strong possibility for a bacterial coinfection in these patients, and that can be very hard to determine because we don’t have a gold standard test for that. Adjunctive diagnostic testing will be necessary if you’re really going to close the loop and implement this as part of an antibiotic stewardship program."

Dr. McCulloh conducted a retrospective chart review of 1,731 children admitted to the hospital for an acute respiratory illness from 2009 to 2011. He then compared the rates of antimicrobial use in children who had the rapid viral panel (809) and those who did not (922). About half of the group (860) had received antibiotics before having the test run, while 255 had received oseltamivir.

Most of the children who had a positive viral panel were prescribed oseltamivir (87%); the drug was used in about 18% of those who had a negative test. A multivariate analysis found that a positive rapid viral panel was the single biggest predictor of getting the antiviral drug, increasing the odds by more than 27 times, Dr. McCulloh said.

Younger age also had a significant association, but the odds ratio was only 1.7. Having a significant past medical history was predictive in an unadjusted analysis, but not in the final model. Abnormal chest x-ray, intensive care unit admission, and abnormal white cell counts had no significant predictive value.

The test also influenced the use of antibiotics, Dr. McCulloh said. Antibiotics were given to 11% of children who had the viral testing, but to 100% of those who did not have it. Antibiotics were used in 51% of those with a positive test, and 67% of those with a negative test. Antibiotics also were discontinued in 6% of children who had a positive viral test.

A multivariate analysis found several factors significantly associated with antibiotic use. A significant past medical history increased the odds by 7%. Stronger predictors included a codiagnosis of acute otitis media (OR 6.0), an abnormal chest x-ray (OR 2.57), and a positive blood culture (OR 3). However, a negative viral panel was associated with a 69% decreased chance of receiving an antibiotic.

The test was a big shaper of physician behavior, Dr. McCulloh said, allowing a more judicious and targeted use of antibiotics while increasing the use of antiviral medication. "Rapid viral panel testing seems to enhance physician decision-making in these patients."

Dr. McCulloh had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The use of radiographs, viral testing, steroids, and bronchodilators for young children with bronchiolitis has declined significantly since the introduction of the American Academy of Pediatrics’ diagnostic and management guidelines.

Before the guidelines were released in 2006 (Pediatrics 2006;118:1774-93), use of all these diagnostic and treatment modalities was on the rise, Dr. Kavita Parikh said at the annual meeting of the Pediatric Academic Societies.

Her retrospective study of more than 130,000 cases demonstrated that the document has had a positive impact on the way bronchiolitis is now managed.

"The AAP practice guideline advocates primarily supportive care," said Dr. Parikh, a pediatric hospitalist at Children’s National Medical Center, Washington. "And as many of us now know, less is more for this illness."

The cases for this study came from a large hospital administration database covering 43 facilities. Dr. Parikh compared diagnostic and treatment resource utilization in three periods: November 2004 to March 2005 (pre-guidelines), November 2007 to March 2008 (early post-guidelines), and November 2011 to March 2012 (late post-guidelines).

The study examined changes in four diagnostic measures (complete blood count [CBC], chest x-rays, respiratory syncytial virus testing, and influenza testing) and three treatment measures (steroids, bronchodilators, and antibiotics).

The study cohort comprised 130,262 children, with a mean age of 4 months. Most (59%) were covered by public insurance.

In the pre-guideline period, CBC was employed in 35% of cases, chest x-ray and RSV testing each in 61%, and influenza testing in 32%. These numbers were essentially unchanged in the early post-guidelines period, but by the late post-guidelines period the recommendations were taking root. All of the measures had decreased significantly: CBC use had gone down by 6%, chest x-rays by about 11%, RSV testing by 20%, and influenza testing by 12%.

Treatment measures changed as well, Dr. Parikh said.

In the pre-guidelines period, steroids were employed in 25% of cases, bronchodilators in 65%, and antibiotics in 34%. Again, the numbers were similar in the early post-guidelines period. By the late post-guidelines period, however, steroid and bronchodilator use had both dropped by 9%. Antibiotic use rose by 3% in the early post-guidelines period but decreased again later for a net change of about 2%. The difference was statistically significant but probably not clinically relevant, Dr. Parikh noted.

"The AAP guidelines have apparently had a positive effect on the way we deal with bronchiolitis, with the greatest impact on chest x-ray, steroid, and bronchodilator use," she said. "We want to continue to look at this and compare local practices to further evaluate implementation by region and hospital type."

Dr. Parikh said that she had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The use of radiographs, viral testing, steroids, and bronchodilators for young children with bronchiolitis has declined significantly since the introduction of the American Academy of Pediatrics’ diagnostic and management guidelines.

Before the guidelines were released in 2006 (Pediatrics 2006;118:1774-93), use of all these diagnostic and treatment modalities was on the rise, Dr. Kavita Parikh said at the annual meeting of the Pediatric Academic Societies.

Her retrospective study of more than 130,000 cases demonstrated that the document has had a positive impact on the way bronchiolitis is now managed.

"The AAP practice guideline advocates primarily supportive care," said Dr. Parikh, a pediatric hospitalist at Children’s National Medical Center, Washington. "And as many of us now know, less is more for this illness."

The cases for this study came from a large hospital administration database covering 43 facilities. Dr. Parikh compared diagnostic and treatment resource utilization in three periods: November 2004 to March 2005 (pre-guidelines), November 2007 to March 2008 (early post-guidelines), and November 2011 to March 2012 (late post-guidelines).

The study examined changes in four diagnostic measures (complete blood count [CBC], chest x-rays, respiratory syncytial virus testing, and influenza testing) and three treatment measures (steroids, bronchodilators, and antibiotics).

The study cohort comprised 130,262 children, with a mean age of 4 months. Most (59%) were covered by public insurance.

In the pre-guideline period, CBC was employed in 35% of cases, chest x-ray and RSV testing each in 61%, and influenza testing in 32%. These numbers were essentially unchanged in the early post-guidelines period, but by the late post-guidelines period the recommendations were taking root. All of the measures had decreased significantly: CBC use had gone down by 6%, chest x-rays by about 11%, RSV testing by 20%, and influenza testing by 12%.

Treatment measures changed as well, Dr. Parikh said.

In the pre-guidelines period, steroids were employed in 25% of cases, bronchodilators in 65%, and antibiotics in 34%. Again, the numbers were similar in the early post-guidelines period. By the late post-guidelines period, however, steroid and bronchodilator use had both dropped by 9%. Antibiotic use rose by 3% in the early post-guidelines period but decreased again later for a net change of about 2%. The difference was statistically significant but probably not clinically relevant, Dr. Parikh noted.

"The AAP guidelines have apparently had a positive effect on the way we deal with bronchiolitis, with the greatest impact on chest x-ray, steroid, and bronchodilator use," she said. "We want to continue to look at this and compare local practices to further evaluate implementation by region and hospital type."

Dr. Parikh said that she had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – The use of radiographs, viral testing, steroids, and bronchodilators for young children with bronchiolitis has declined significantly since the introduction of the American Academy of Pediatrics’ diagnostic and management guidelines.

Before the guidelines were released in 2006 (Pediatrics 2006;118:1774-93), use of all these diagnostic and treatment modalities was on the rise, Dr. Kavita Parikh said at the annual meeting of the Pediatric Academic Societies.

Her retrospective study of more than 130,000 cases demonstrated that the document has had a positive impact on the way bronchiolitis is now managed.

"The AAP practice guideline advocates primarily supportive care," said Dr. Parikh, a pediatric hospitalist at Children’s National Medical Center, Washington. "And as many of us now know, less is more for this illness."

The cases for this study came from a large hospital administration database covering 43 facilities. Dr. Parikh compared diagnostic and treatment resource utilization in three periods: November 2004 to March 2005 (pre-guidelines), November 2007 to March 2008 (early post-guidelines), and November 2011 to March 2012 (late post-guidelines).

The study examined changes in four diagnostic measures (complete blood count [CBC], chest x-rays, respiratory syncytial virus testing, and influenza testing) and three treatment measures (steroids, bronchodilators, and antibiotics).

The study cohort comprised 130,262 children, with a mean age of 4 months. Most (59%) were covered by public insurance.

In the pre-guideline period, CBC was employed in 35% of cases, chest x-ray and RSV testing each in 61%, and influenza testing in 32%. These numbers were essentially unchanged in the early post-guidelines period, but by the late post-guidelines period the recommendations were taking root. All of the measures had decreased significantly: CBC use had gone down by 6%, chest x-rays by about 11%, RSV testing by 20%, and influenza testing by 12%.

Treatment measures changed as well, Dr. Parikh said.

In the pre-guidelines period, steroids were employed in 25% of cases, bronchodilators in 65%, and antibiotics in 34%. Again, the numbers were similar in the early post-guidelines period. By the late post-guidelines period, however, steroid and bronchodilator use had both dropped by 9%. Antibiotic use rose by 3% in the early post-guidelines period but decreased again later for a net change of about 2%. The difference was statistically significant but probably not clinically relevant, Dr. Parikh noted.

"The AAP guidelines have apparently had a positive effect on the way we deal with bronchiolitis, with the greatest impact on chest x-ray, steroid, and bronchodilator use," she said. "We want to continue to look at this and compare local practices to further evaluate implementation by region and hospital type."

Dr. Parikh said that she had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Delaying some early childhood vaccinations seems to double the risk that a child will experience a vaccine-related febrile seizure.

The finding is concerning as more and more parents ask about delaying or spacing out vaccines to avoid perceived harm from giving "too many [vaccines], too close together," Dr. Simon J. Hambidge said at the annual meeting of the Pediatric Academic Societies.

The observed risk in febrile seizures with vaccine delays may be explained physiologically by the child’s increased ability to mount a vigorous immune response. When children mount a better immune response, they’re more likely to have a fever. Further, febrile seizures begin to rise in toddlers between the ages of 16 and 23 months.

"It’s a complicated relationship. ... I think it’s clear that there is something going on at this time of life that’s increasing the risk of febrile seizures," said Dr. Hambidge, professor of pediatrics at the Colorado School of Public Health, Denver.

Dr. Hambidge examined the rate of vaccine-related febrile seizures in a cohort of 324,000 children who were born from 2004-2008. The study population was derived from eight large health care sites, all of which participate in the Vaccine Safety DataLink program. All children were seen in an emergency department or hospital for a febrile seizure at 93-730 days of age.

A self-controlled case series analysis accounted for associations between time (pre- and post vaccination) and exposure (vaccinated or not during the exposure windows). Based on known risks for fever after vaccination, the exposure risk window was set at 0-2 days after vaccination for inactive vaccines; the exposure risk window was 7-10 days afterward for live vaccines. The final measure was an incidence rate ratio (IRR).

The first analysis examined febrile seizures in the group that had infant vaccines administered according to the usual schedule. These included the DTaP (diphtheria, tetanus, and pertussis), conjugated pneumococcal, polio, coronavirus, Haemophilus influenzae type b, and rotavirus vaccines.

"There were no statistically significant differences in the IRR after any of these vaccines, whether they were given on time or delayed," Dr. Hambidge said. "I think this reflects the paucity of seizures generally seen during the first year of life."

For vaccines given during the second year of life, the IRR was examined for measles, mumps, rubella (MMR) and for measles, mumps, rubella, and varicella (MMRV) given on the usual schedule (12-15 months) and on a delayed schedule (16-23 months).

For babies who got the MMR on schedule, the IRR was 2.5, "corresponding to an attributable risk of about 1 [febrile seizure] in 4,000 doses," Dr. Hambidge said. When the MMR was delayed until the baby was 16-23 months old, the IRR significantly increased to 7.7 – an attributable risk of about 2 seizures per 4,000 doses.

A similar doubling of risk with the delayed schedule occurred with the MMRV vaccine, he said. Given at the normal schedule of 12-15 months, the IRR was 4.6, a risk of about one febrile seizure for every 2,000 vaccine doses. But when the MMRV was given at 16-23 months, the IRR rose to just above 15 – doubling the attributable risk to about 2 febrile seizures per 2,000 doses.

Parents should understand these risks but can be somewhat reassured that a febrile seizure isn’t generally a sign of something more sinister, Dr. Hambidge said in an interview.

"Kids with postvaccination febrile seizures have acute febrile seizures. None have gone on to develop epilepsy or have lasting problems. So the seizures are scary for parents, but typically result in a trip to the emergency department and then recovery. Still, it’s better to get the vaccines on time, rather than late, to minimize this risk," he said.

This study was funded through a subcontract with America’s Health Insurance Plans from the Centers for Disease Control and Prevention. Dr. Hambidge had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Delaying some early childhood vaccinations seems to double the risk that a child will experience a vaccine-related febrile seizure.

The finding is concerning as more and more parents ask about delaying or spacing out vaccines to avoid perceived harm from giving "too many [vaccines], too close together," Dr. Simon J. Hambidge said at the annual meeting of the Pediatric Academic Societies.

The observed risk in febrile seizures with vaccine delays may be explained physiologically by the child’s increased ability to mount a vigorous immune response. When children mount a better immune response, they’re more likely to have a fever. Further, febrile seizures begin to rise in toddlers between the ages of 16 and 23 months.

"It’s a complicated relationship. ... I think it’s clear that there is something going on at this time of life that’s increasing the risk of febrile seizures," said Dr. Hambidge, professor of pediatrics at the Colorado School of Public Health, Denver.

Dr. Hambidge examined the rate of vaccine-related febrile seizures in a cohort of 324,000 children who were born from 2004-2008. The study population was derived from eight large health care sites, all of which participate in the Vaccine Safety DataLink program. All children were seen in an emergency department or hospital for a febrile seizure at 93-730 days of age.

A self-controlled case series analysis accounted for associations between time (pre- and post vaccination) and exposure (vaccinated or not during the exposure windows). Based on known risks for fever after vaccination, the exposure risk window was set at 0-2 days after vaccination for inactive vaccines; the exposure risk window was 7-10 days afterward for live vaccines. The final measure was an incidence rate ratio (IRR).

The first analysis examined febrile seizures in the group that had infant vaccines administered according to the usual schedule. These included the DTaP (diphtheria, tetanus, and pertussis), conjugated pneumococcal, polio, coronavirus, Haemophilus influenzae type b, and rotavirus vaccines.

"There were no statistically significant differences in the IRR after any of these vaccines, whether they were given on time or delayed," Dr. Hambidge said. "I think this reflects the paucity of seizures generally seen during the first year of life."

For vaccines given during the second year of life, the IRR was examined for measles, mumps, rubella (MMR) and for measles, mumps, rubella, and varicella (MMRV) given on the usual schedule (12-15 months) and on a delayed schedule (16-23 months).

For babies who got the MMR on schedule, the IRR was 2.5, "corresponding to an attributable risk of about 1 [febrile seizure] in 4,000 doses," Dr. Hambidge said. When the MMR was delayed until the baby was 16-23 months old, the IRR significantly increased to 7.7 – an attributable risk of about 2 seizures per 4,000 doses.

A similar doubling of risk with the delayed schedule occurred with the MMRV vaccine, he said. Given at the normal schedule of 12-15 months, the IRR was 4.6, a risk of about one febrile seizure for every 2,000 vaccine doses. But when the MMRV was given at 16-23 months, the IRR rose to just above 15 – doubling the attributable risk to about 2 febrile seizures per 2,000 doses.

Parents should understand these risks but can be somewhat reassured that a febrile seizure isn’t generally a sign of something more sinister, Dr. Hambidge said in an interview.

"Kids with postvaccination febrile seizures have acute febrile seizures. None have gone on to develop epilepsy or have lasting problems. So the seizures are scary for parents, but typically result in a trip to the emergency department and then recovery. Still, it’s better to get the vaccines on time, rather than late, to minimize this risk," he said.

This study was funded through a subcontract with America’s Health Insurance Plans from the Centers for Disease Control and Prevention. Dr. Hambidge had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Delaying some early childhood vaccinations seems to double the risk that a child will experience a vaccine-related febrile seizure.

The finding is concerning as more and more parents ask about delaying or spacing out vaccines to avoid perceived harm from giving "too many [vaccines], too close together," Dr. Simon J. Hambidge said at the annual meeting of the Pediatric Academic Societies.

The observed risk in febrile seizures with vaccine delays may be explained physiologically by the child’s increased ability to mount a vigorous immune response. When children mount a better immune response, they’re more likely to have a fever. Further, febrile seizures begin to rise in toddlers between the ages of 16 and 23 months.

"It’s a complicated relationship. ... I think it’s clear that there is something going on at this time of life that’s increasing the risk of febrile seizures," said Dr. Hambidge, professor of pediatrics at the Colorado School of Public Health, Denver.

Dr. Hambidge examined the rate of vaccine-related febrile seizures in a cohort of 324,000 children who were born from 2004-2008. The study population was derived from eight large health care sites, all of which participate in the Vaccine Safety DataLink program. All children were seen in an emergency department or hospital for a febrile seizure at 93-730 days of age.

A self-controlled case series analysis accounted for associations between time (pre- and post vaccination) and exposure (vaccinated or not during the exposure windows). Based on known risks for fever after vaccination, the exposure risk window was set at 0-2 days after vaccination for inactive vaccines; the exposure risk window was 7-10 days afterward for live vaccines. The final measure was an incidence rate ratio (IRR).

The first analysis examined febrile seizures in the group that had infant vaccines administered according to the usual schedule. These included the DTaP (diphtheria, tetanus, and pertussis), conjugated pneumococcal, polio, coronavirus, Haemophilus influenzae type b, and rotavirus vaccines.

"There were no statistically significant differences in the IRR after any of these vaccines, whether they were given on time or delayed," Dr. Hambidge said. "I think this reflects the paucity of seizures generally seen during the first year of life."

For vaccines given during the second year of life, the IRR was examined for measles, mumps, rubella (MMR) and for measles, mumps, rubella, and varicella (MMRV) given on the usual schedule (12-15 months) and on a delayed schedule (16-23 months).

For babies who got the MMR on schedule, the IRR was 2.5, "corresponding to an attributable risk of about 1 [febrile seizure] in 4,000 doses," Dr. Hambidge said. When the MMR was delayed until the baby was 16-23 months old, the IRR significantly increased to 7.7 – an attributable risk of about 2 seizures per 4,000 doses.

A similar doubling of risk with the delayed schedule occurred with the MMRV vaccine, he said. Given at the normal schedule of 12-15 months, the IRR was 4.6, a risk of about one febrile seizure for every 2,000 vaccine doses. But when the MMRV was given at 16-23 months, the IRR rose to just above 15 – doubling the attributable risk to about 2 febrile seizures per 2,000 doses.

Parents should understand these risks but can be somewhat reassured that a febrile seizure isn’t generally a sign of something more sinister, Dr. Hambidge said in an interview.

"Kids with postvaccination febrile seizures have acute febrile seizures. None have gone on to develop epilepsy or have lasting problems. So the seizures are scary for parents, but typically result in a trip to the emergency department and then recovery. Still, it’s better to get the vaccines on time, rather than late, to minimize this risk," he said.

This study was funded through a subcontract with America’s Health Insurance Plans from the Centers for Disease Control and Prevention. Dr. Hambidge had no financial disclosures.

msullivan@frontlinemedcom.com

WASHINGTON – Children as young as 3-5 years old appear to be at risk for developing hypertension if they become overweight or obese as they grow.

Prehypertension was 57% more likely to develop in children who went from being of normal weight to being overweight, and hypertension was almost twice as likely to develop, compared with children who maintained a normal weight, *Dr. Elyse Kharbanda, reported at the annual meeting of the Pediatric Academic Societies.

The picture was even grimmer for the 10% of children who remained obese during the entire 2.5-year study, said *Dr. Kharbanda of HealthPartners Institute for Education and Research, Bloomington, Minn. Those children were more than twice as likely to develop incident prehypertension and nearly four times as likely to develop incident hypertension.

Her study examined trends in weight and blood pressure among 59,638 children aged 3-17 years. The children were drawn from three large insurance data sets in northern California, Colorado, and Minnesota from the time period of 2007-2010. All of the children had visited a health care facility in their group at least four times during the study period, and all had normal blood pressure at the first visit.

About half (45%) of the children were white, 11% were black, 8% Asian, and 7% Hispanic; other ethnicities made up the remainder of the cohort. Age ranges were 3-5 years (27%), 6-8 years (17%), 9-11 years (21%), 12-14 years (22%), and 15-17 years (13%).

For the study, normal weight was defined as a body mass index in the 5th to less than 85th percentile, while overweight was defined as BMI in the 85th to less than 95th percentile. Obesity was defined as a BMI in the 95th percentile or greater.

At baseline, mean BMI was in the 64th percentile. The children’s mean baseline blood pressure was in the 39th percentile for systolic and 50th for diastolic.

Over the study period, 65% of the children maintained a normal weight, 8% remained overweight, and 10% remained obese. Nine percent of the group increased in weight, either from a healthy weight to overweight, or from overweight to obese. Eight percent of the children lost weight, going from overweight to normal weight or from obese to overweight.

During the study period, there were 16,102 new cases of prehypertension (27%) and 597 cases of incident hypertension (1%).

A multivariate analysis controlled for age, race, study site, and systolic blood pressure at baseline. In the fully adjusted model, compared with children who maintained a healthy weight, those who became overweight or obese were 57% more likely to develop prehypertension. Children who stayed overweight were 49% more likely to develop prehypertension, and those who remained obese were 2.3 times more likely to develop prehypertension. All of the differences were statistically significant.

Children who increased from one weight category to the next were 87% more likely to develop hypertension. The increased risk was 28% for those who stayed overweight and 3.6% for those who remained obese. Again, the changes were statistically significant.

The analysis also found significant differences in progression from prehypertension to hypertension. Children whose weight category increased were 27% more likely to progress, and those who stayed obese, 86% more likely. Children who stayed overweight were not significantly more likely to progress from prehypertension to hypertension, Dr. Kharbanda said.

She had no financial disclosures.

msullivan@frontlinemedcom.com

*Correction 5/10/13: The photo and reference to the presenter of the study that originally accompanied this article were incorrect. The presenter of the study was Dr. Elyse Kharbanda, of HealthPartners Institute for Education and Research, Bloomington, Minn.

WASHINGTON – Children as young as 3-5 years old appear to be at risk for developing hypertension if they become overweight or obese as they grow.

Prehypertension was 57% more likely to develop in children who went from being of normal weight to being overweight, and hypertension was almost twice as likely to develop, compared with children who maintained a normal weight, *Dr. Elyse Kharbanda, reported at the annual meeting of the Pediatric Academic Societies.

The picture was even grimmer for the 10% of children who remained obese during the entire 2.5-year study, said *Dr. Kharbanda of HealthPartners Institute for Education and Research, Bloomington, Minn. Those children were more than twice as likely to develop incident prehypertension and nearly four times as likely to develop incident hypertension.

Her study examined trends in weight and blood pressure among 59,638 children aged 3-17 years. The children were drawn from three large insurance data sets in northern California, Colorado, and Minnesota from the time period of 2007-2010. All of the children had visited a health care facility in their group at least four times during the study period, and all had normal blood pressure at the first visit.

About half (45%) of the children were white, 11% were black, 8% Asian, and 7% Hispanic; other ethnicities made up the remainder of the cohort. Age ranges were 3-5 years (27%), 6-8 years (17%), 9-11 years (21%), 12-14 years (22%), and 15-17 years (13%).

For the study, normal weight was defined as a body mass index in the 5th to less than 85th percentile, while overweight was defined as BMI in the 85th to less than 95th percentile. Obesity was defined as a BMI in the 95th percentile or greater.

At baseline, mean BMI was in the 64th percentile. The children’s mean baseline blood pressure was in the 39th percentile for systolic and 50th for diastolic.

Over the study period, 65% of the children maintained a normal weight, 8% remained overweight, and 10% remained obese. Nine percent of the group increased in weight, either from a healthy weight to overweight, or from overweight to obese. Eight percent of the children lost weight, going from overweight to normal weight or from obese to overweight.

During the study period, there were 16,102 new cases of prehypertension (27%) and 597 cases of incident hypertension (1%).

A multivariate analysis controlled for age, race, study site, and systolic blood pressure at baseline. In the fully adjusted model, compared with children who maintained a healthy weight, those who became overweight or obese were 57% more likely to develop prehypertension. Children who stayed overweight were 49% more likely to develop prehypertension, and those who remained obese were 2.3 times more likely to develop prehypertension. All of the differences were statistically significant.

Children who increased from one weight category to the next were 87% more likely to develop hypertension. The increased risk was 28% for those who stayed overweight and 3.6% for those who remained obese. Again, the changes were statistically significant.

The analysis also found significant differences in progression from prehypertension to hypertension. Children whose weight category increased were 27% more likely to progress, and those who stayed obese, 86% more likely. Children who stayed overweight were not significantly more likely to progress from prehypertension to hypertension, Dr. Kharbanda said.

She had no financial disclosures.

msullivan@frontlinemedcom.com

*Correction 5/10/13: The photo and reference to the presenter of the study that originally accompanied this article were incorrect. The presenter of the study was Dr. Elyse Kharbanda, of HealthPartners Institute for Education and Research, Bloomington, Minn.

WASHINGTON – Children as young as 3-5 years old appear to be at risk for developing hypertension if they become overweight or obese as they grow.

Prehypertension was 57% more likely to develop in children who went from being of normal weight to being overweight, and hypertension was almost twice as likely to develop, compared with children who maintained a normal weight, *Dr. Elyse Kharbanda, reported at the annual meeting of the Pediatric Academic Societies.

The picture was even grimmer for the 10% of children who remained obese during the entire 2.5-year study, said *Dr. Kharbanda of HealthPartners Institute for Education and Research, Bloomington, Minn. Those children were more than twice as likely to develop incident prehypertension and nearly four times as likely to develop incident hypertension.

Her study examined trends in weight and blood pressure among 59,638 children aged 3-17 years. The children were drawn from three large insurance data sets in northern California, Colorado, and Minnesota from the time period of 2007-2010. All of the children had visited a health care facility in their group at least four times during the study period, and all had normal blood pressure at the first visit.

About half (45%) of the children were white, 11% were black, 8% Asian, and 7% Hispanic; other ethnicities made up the remainder of the cohort. Age ranges were 3-5 years (27%), 6-8 years (17%), 9-11 years (21%), 12-14 years (22%), and 15-17 years (13%).

For the study, normal weight was defined as a body mass index in the 5th to less than 85th percentile, while overweight was defined as BMI in the 85th to less than 95th percentile. Obesity was defined as a BMI in the 95th percentile or greater.

At baseline, mean BMI was in the 64th percentile. The children’s mean baseline blood pressure was in the 39th percentile for systolic and 50th for diastolic.

Over the study period, 65% of the children maintained a normal weight, 8% remained overweight, and 10% remained obese. Nine percent of the group increased in weight, either from a healthy weight to overweight, or from overweight to obese. Eight percent of the children lost weight, going from overweight to normal weight or from obese to overweight.

During the study period, there were 16,102 new cases of prehypertension (27%) and 597 cases of incident hypertension (1%).

A multivariate analysis controlled for age, race, study site, and systolic blood pressure at baseline. In the fully adjusted model, compared with children who maintained a healthy weight, those who became overweight or obese were 57% more likely to develop prehypertension. Children who stayed overweight were 49% more likely to develop prehypertension, and those who remained obese were 2.3 times more likely to develop prehypertension. All of the differences were statistically significant.

Children who increased from one weight category to the next were 87% more likely to develop hypertension. The increased risk was 28% for those who stayed overweight and 3.6% for those who remained obese. Again, the changes were statistically significant.

The analysis also found significant differences in progression from prehypertension to hypertension. Children whose weight category increased were 27% more likely to progress, and those who stayed obese, 86% more likely. Children who stayed overweight were not significantly more likely to progress from prehypertension to hypertension, Dr. Kharbanda said.

She had no financial disclosures.

msullivan@frontlinemedcom.com

*Correction 5/10/13: The photo and reference to the presenter of the study that originally accompanied this article were incorrect. The presenter of the study was Dr. Elyse Kharbanda, of HealthPartners Institute for Education and Research, Bloomington, Minn.